The stage is set and the instruments are in place. Waiting in the wings, her heart is racing, her hands are trembling and her stomach is nauseous. It is show time. But, this isn’t a concert–it is a simulation designed to help nursing students develop clinical skills such as setting up and monitoring IVs, administering injections, inserting catheters and many other clinical techniques that must be mastered to become effective registered nurses. However, the anxiety experienced by some nursing students is similar to what musicians, actors, and athletes feel before playing a musical piece, reciting their lines or running a race.

Nursing simulations are an important part of the curriculum at the Texas A&M Health Science Center College of Nursing. Simulations allow students to put the theory that they learn from lectures and readings into action. Students practice real or nearly real techniques on either standardized patients or manikins, while receiving feedback on the critical aspects of what they do and say throughout the simulation. Students are aware that the simulation is being watched by their professor from a remote location, that they are being recorded and that mastering clinical skills is an important part of their nursing education.

While simulations are an invaluable opportunity for students to learn, practice and correct mistakes in a controlled environment, these highly-monitored clinical situations and the weight of their importance, can be extremely stressful.

“Nursing students can experience performance anxiety before and during their clinical simulations,” said Kevin Gosselin, associate professor and assistant dean for graduate studies. “While a certain degree of anxiety is natural, and maybe even helpful, too much anxiety prevents students from learning and demonstrating what they are capable of accomplishing.”

Gosselin leads a team of nursing faculty who are conducting research on how nursing students might better manage their performance anxiety as participants in clinical simulations. The idea for the study originated from a discussion that Gosselin and Brian Holland, assistant professor and assistant dean for undergraduate studies, had regarding student’s responses to the simulations.

“Kevin and I are both musicians, and we noticed similarities in the type of anxiety that we experience when performing in front of an audience, and in our student’s anxiety when they participate in clinical simulations,” Holland said. “So we began looking at options that might help students to better manage their anxiety.”

Anxiety is a combination of psychological and physical symptoms triggered by a perceived threat. In the case of nursing simulations, anxiety felt by students may stem from the combination of life-like clinical scenarios with standardized patients and the level of scrutiny required to accurately evaluate their skills. Although it is natural for students to experience some anxiety in the simulation setting, too much anxiety can hinder their ability to learn, diminish self-confidence and result in underperformance.

Anxiety symptoms vary from one individual to another, depending on the nature and magnitude of the perceived threat. Increased heart rate and blood pressure, tremors and dizziness are some of the symptoms that can impact a student’s ability to perform. Although the study looked at several therapeutic options including music, autogenic training and movement as a way to decrease performance anxiety for nursing students in their simulations, music seemed to have the greatest impact.

“Music is widely used in health care as a therapy to reduce pain and to comfort patients,”Gosselin said. “So it made sense for the study to emphasize the difference that music made in our student’s anxiety and performance levels.”

Nursing students were randomly assigned to either the experimental group or to a control group, and they were evaluated pre and post-simulation for their anxiety, self-confidence and clinical skills levels. Researchers selected classical music that was primarily instrumental, with little to no brass instruments and pieces with rhythms slower than a natural heartbeat (60-80 beats per minute).

Students in the experimental group who listened to 30 minutes of classical music showed notable differences when compared to their counterparts in the control group. Heart rates, mean arterial pressures and state-trait anxiety scores were significantly lower in students in the experimental group, and their instructor performance ratings were significantly higher than those for students in the control group. There was no measurable difference between the self-confidence of students in the experimental or control groups.

After reviewing the data, researchers took their findings to students in the control group to share how listening to classical music prior to the simulations affected the students in the experimental group. As a consequence, several students in the control group reportedly listened to music just before sitting for their Objective Structured Clinical Examination (OSCE).

“I am not sure if students found it helpful in preparing to take the OSCE, but the data suggests that music intervention has the potential to reduce anxiety and improve student performance in a testing environment,” Gosselin said. “The findings were almost surprising because music intervention can so easily, effectively and inexpensively help diminish the negative effects of anxiety experienced by nursing students in simulations, resulting in better nursing care and improved patient outcomes, not just in the simulation, but also in their nursing practice.”

— Diane L. Oswald

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